A randomized comparison of fluoroscopic techniques for implanting pacemaker lead on the right ventricular outflow tract septum

Abstract

Right ventricular outflow tract (RVOT) septal pacing is commonly performed under the standard fluoroscopic positions during procedure. The aim of the prospective, randomized study was to evaluate the accuracy of the combination of standard fluoroscopic and left lateral (LL) fluoroscopic views for determination of RVOT septal position compared with standard fluoroscopic views alone. We prospectively enrolled patients who had indications for implantation of a permanent pacemaker. Patients were randomly assigned into two groups based on intraoperative fluoroscopic views as follows: LL group (three standard fluoroscopic views + LL fluoroscopic view) or standard group (three standard fluoroscopic views). Transthoracic echocardiography (TTE) determination of pacing sites was applied in all patients 3 days after pacemaker implantation. The implantation success rate of RVOT septal pacing was compared between groups. A total of 143 patients (59 males, mean age 57.6 ± 16.3 years) with symptomatic bradyarrhythmia were studied, of whom, 72 patients were randomized to LL group and 71 to standard group. TTE determination of pacing sites was compared with two groups. In the LL group, 60 patients (83 %) were achieved in RVOT septal position. In the standard group, however, the position of RVOT septum was only observed in 48 patients (68 %). The success rate of RVOT septal position in LL group was significantly higher than standard group (p = 0.029). Comparing to traditional views, combining LL view in the procedure will approve the accuracy of RVOT septal pacing site.

Single‐chamber leadless pacemaker for atrial synchronous or ventricular pacing

“…[31][32][33][34][35][36] To ensure a septal location, the LP device should be directed toward the left in the LAO view and away from the sternum in the left lateral view. [33][34][35][36] The absence of notching in the inferior leads during pacing is suggestive of a septal location. 33 After confirmation of correct placement, the LP device is deployed.…”

Individualized Left Anterior Oblique Projection

“…5,6 However, the inferior border of the heart is often difficult to see in RAO 30° to 40° because of the superimposition with the diaphragm silhouette, and the segmentation of the heart in quadrants can be arbitrary. The use of the left lateral projection has also been reported to be valuable 7 ; but this projection is usually difficult to per- form during the implant procedure without compromising the sterile surgical field. Nevertheless, these additional fluoroscopy projections remain somewhat unsatisfactory in the fact that they are unadjusted to the patient's anatomy and might lead to flawed conclusions.…”

“…The right anterior oblique (RAO) 30° to 40° projection has been suggested to be useful when associated to the LAO 40°, 5,6 as well as the left lateral projection. 7 However, cardiac long-axis orientation present an important interindividual variability 8 and the use of the same generic fluoroscopy projections for every patient remains unsatisfactory.…”

Ventricular septal pacing: Optimum method to position the lead

“…Chen et al also have emphasized the importance of fluoroscopic LL view. 27 Using post-implant transthoracic echocardiogram as confirmatory imaging modality they have shown conventional fluoroscopic LAO angulation has only 68% specificity whereas LL has specificity of 83% in predicting septal location of the RV pacing lead.…”

“…of patients Stylet used Fluoroscopic projection used Confirmatory imaging used Success rate Advantages/Limitations Rosso et al 35 2010 100 Mond’s stylet PA, LAO,RAO Electrocardiography 90% Limitations of ECG for localizing septal position of the RV lead demonstrated in several subsequent studies Mond et al 22 2012 113 2D stylet was compared with 3D stylet PA, LAO,RAO Echocardiography Inclusion of RAO fluoroscopy and 3D stylet lead to success rate of 97% Echocardiography is very much angle and operator dependent McGavigan et al 23 2014 Modified Mond’s stylet PA, LAO,RAO Proposed technique requires right ventriculogram during lead implantation and the method was not validated with any confirmatory imaging. Burri et al 24 2013 51 Modified Mond’s stylet LAO, RAO CT angiography Combining RAO fluoroscopy increased the success rate from 41 to 96.4% success rate of 97% CT angiography is gold standard Chen et al 27 2016 143 Mond’s stylet PA, LAO, RAO, LL Echocardiography LL view increased the specificity than conventional 3 views (68% vs. 83%) Very much angle and operator dependent Pang et al 33 2014 35 Mon...…”